How did I get here, Talking Heads asked around 1981. They probably didn’t realise their question would apply to general practice 33 years later. It does, though, in so many ways. And this month’s examples of utter, furious, GP bewilderment are brought to you via the blinkered, one-dimensional thinking of hospital departments apparently hell-bent on screwing up patients and driving us to goggle-eyed distraction.
Three cases against the accused:
1 I refer an elderly diamond geezer with new-onset dyspepsia and weight loss to the upper GI team, as you do. He’s seen within the statutory two weeks, and has the requisite scopes and scans. So far so good. His tests turn up some suspicious lesions in lungs and liver, and a nasty-looking probable primary in his bladder. So after the obligatory multidisciplinary team humming and hawing, he’s referred to the urologist – and if you think you can hear the gears of the merry-go-round cranking up, you’re right.
He has his cystoscopy and, amazingly, it’s normal. The bladder finding was artefactual. So he hops off the carousel and finds he’s back where he started, with me, because the urologist has referred him back to the GP for further management. Still dyspeptic, still losing weight and still with unexplained lesions in lungs and liver. Thanks, chaps.
2 I refer another patient to the medical assessment unit. A 62-year-old rare attender, he has a mysteriously swollen, painful leg which he can barely walk on, plus he feels hot and unwell. It’s definitely a something, but not obviously anything: too feverish for a DVT, too swollen for cellulitis, too ill for trauma. I explain to the medical SHO that he needs a proper overhaul, deliberately avoiding the diagnostic cul-de-sac of the DVT pathway. So, obviously, they direct him straight down the diagnostic cul-de-sac of the DVT pathway. That’s why my next contact with him is at 5.45pm on a Friday, just after he hears from the DVT nurse that he doesn’t have a DVT, but that, because he is still ill, leg-swollen and unable to bear weight, he should phone his GP for further advice.
3 I get a letter from the psychiatric unit. My patient, a chronic schizophrenic with multiple previous admissions for psychotic episodes, has DNA’d for the outpatient clinic. So, ‘as per trust policy’, they’re discharging him ‘to my care’. Because, obviously, the failure of a chronic schizophrenic to show up is nothing to do with the social chaos of the mentally ill, or the amnesic effects of industrial-strength psychotropics, or the addling result of worsening psychosis – no, it’s wilful wastefulness on the part of the patient. And that, clearly, is now my problem.
Voilà. Care that is consistently unidirectional, relentlessly dysfunctional and distressingly mononeuronal. This is what happens when you deconstruct illness and its management, and run the NHS by pathway and protocol. It’s getting worse and, to be honest, it’s a bit depressing. Care pathway? More like a road to nowhere.
Dr Tony Copperfield is a GP in Essex. You can follow him on Twitter @DocCopperfield.